Basic Information
| Provider Information | |||||||||
| NPI: | 1588684344 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEMBERTON | ||||||||
| FirstName: | PHYLLIS | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1416 RIVER OAKS DR | ||||||||
| Address2: | |||||||||
| City: | JACKSONS GAP | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368613126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568251456 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3316 HIGHWAY 280 | ||||||||
| Address2: | |||||||||
| City: | ALEXANDER CITY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350103369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563297120 | ||||||||
| FaxNumber: | 2563297600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 1017898 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 51050952 | 01 | AL | BLUE CROSS PROVIDER NUMBE | OTHER |